The Department of Veterans Affairs Office of Inspector General (VAOIG) released a report on April 17 that investigated the suicides of three mental-health patients under the supervision of the Atlanta VA Medical Center in Decatur, Ga.

The report said the "lack of effective patient care management and program oversight by the (Atlanta) facility contributed to problems with access to MH (mental health) care and contributed to ‘patients falling through the cracks.'" The three individuals who died were among the 4,000 to 5,000 patients referred by the VA hospital to the DeKalb Community Service Board (CSB) since 2010.

According to an April 19 article in the Atlanta Journal-Constitution, one patient died of an apparent drug overdose after waiting almost a year to see a psychiatrist; another was told to take public transportation to an emergency department because a psychiatrist was not available (he didn't go and committed suicide the next day); a third patient, who was supposed to be closely monitored, died of a drug overdose after hospital staff members lost track of him for two hours.

Robert Petzel, VA's under secretary for health, received a letter today signed by three House representatives from Georgia: Phil Gingrey, David Scott and Tom Price, M.D. They wrote "it is inexcusable that these events have been allowed to take place. It is reprehensible that a federal audit was necessary to bring these tragic events to light, and we would like to seek assurances that nothing similar will happen in the future. In addition, we would like to know how the situation was allowed to get so out of hand before anything was done to rectify it."

The VAOIG report substantiated that:

The administrative and managerial difficulties increased as more patients were referred on the DeKalb CSB contract,

The VA facility had not established an effective tracking and monitoring systems for patients referred to the CSB; program managers were unable to identify the enrolled CSB patients, and

An effective quality assurance program had not been established the VA facility and the CSB.

"Fragmented and uncoordinated care," the report noted, "may have contributed to delays in accessing MH treatment. Our review also confirmed that facility managers did not provide adequate staff, training, resources, support, or guidance for effective oversight of the contracted MH program."

The wait list for mental health treatment at the Atlanta facility, according to VAOIG, increased from 53 to 397 patients from 2011 to 2012, and there were 66 vacant staff positions.